Colorectal Cancer Pathway Board Annual Report 2014/15

Pathway Clinical Director: Sarah Duff Pathway Manager: Melissa Wright

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Executive summary 1. The Colorectal Cancer Pathway Board consists of two separate but linked groups, the

Pathway Board and the Clinical Subgroup. The Pathway Board has representatives of professional groups involved in all stages of the patient journey and representation from each trust. The Clinical Subgroup involves more clinicians from each trust to facilitate engagement and dissemination of plans throughout all secondary care sites. The groups meet alternately every two months, minutes of each meeting are circulated to all and the groups share the Annual Report and Annual Plan.

2. The 2013-2014 Annual Plan set out the work plan for the Colorectal Cancer Pathway

Board and the areas addressed will be considered in the context of Manchester Cancer’s overarching objectives:

2.1 Improving outcomes, with a focus on survival To increase screening uptake to above the national average (by 2019)

Development of a project with Public Health England and Bowel Cancer Screening to encouragement re-engagement with screening following a positive screening test

project adopted by national ACE (accelerate, coordinate, evaluate) program

GP education morning with HPB and Upper GI pathways on screening and early diagnosis

2.2 Improving patient experience To improve patients experience of care in line with the National Cancer Survivorship initiative (by 2019)

regional survey of survivorship activities

creation of regional Colorectal Nurse Specialist group to enhance survivorship activity

successful application to Macmillan Innovation Fund to appoint project manager to support CNS group and develop this area further

2.3 Increasing research and clinical innovation Enhance recruitment of colorectal patients to clinical trials (by Aug 2017)

Regular agenda item at all meetings

2.4 Delivering and high quality, compliant, coordinated and equitable services To update network guidelines (by Aug 2016) To monitor, measure and assess colorectal cancer services across the region (by Aug 2016)

New guidelines and pathways written and agreed and several old guidelines updated

Regular data review at each meeting including Cancer Wait Time data, screening uptake data, NCPES, National Bowel Cancer Audit data.

Outlying performance on NBOCA data addressed with trusts involved directly and responses fed back to Manchester Cancer Core Team for discussion with Provider Board

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3. Challenges faced by Colorectal Cancer Pathway Board

Patient involvement is lacking within the Colorectal Cancer Pathway Board. This will be addressed with the Macmillan User Involvement Team.

Attendance by some trusts/representatives at meetings has been poor. This has been raised with the trusts/representatives directly but may require Provider Board input to change.

Development of services for patients Living With and Beyond Cancer takes time and effort and relies on CNSs in busy jobs to implement change. The Macmillan Innovation Funding to support the CNS group offers an opportunity to enhance provision of these services. This should be recognised as a priority by the Provider Board and trusts encouraged to use this funding to develop services before this become a requirement of commissioning.

Barriers to uptake of research studies at individual trusts have not been investigated and will be addressed in the coming year.

All trusts struggle to meet the 62 day target and change to diagnostic pathways may be required to achieve this. The regional 62 day audit has led to suggestions for pathway redesign which are currently being discussed and will require Provider Board direction and support to implement when they are decided.

Guideline update has been slow and requires more clinical input from members of the Pathway Board. A detailed plan of guidelines requiring update will be developed.

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Introduction – the Pathway Board and its vision This is the annual report of the Manchester Cancer Colorectal Cancer Pathway Board for 2014/15. This annual report is designed to:

Provide a summary of the work programme, outcomes and progress of the Board – alongside the minutes of its meetings, its action plan and its scorecard - it is the key document for the Board.

Provide an overview to the hospital trust CEOs and other interested parties about the current situation across Manchester Cancer in this particular cancer area

Meet the requirements of the National Cancer Peer Review Programme

Be openly published on the external facing website. This annual report outlines how the Pathway Board has contributed in 2014/15 to the achievement of Manchester Cancer’s four overarching objectives:

Improving outcomes, with a focus on survival

Improving patient experience

Increasing research and clinical innovation

Delivering and high quality, compliant, coordinated and equitable services

1.1. Vision

The Colorectal Cancer Pathway Board has built on the progress of the work undertaken by the previous Greater Manchester and Cheshire Cancer Network Site Specific Group (GMCCN) and has developed a clear emphasis on the whole pathway of cancer to ensure the delivery of a high quality service that will improve survival and outcomes and the patient experience of care. The membership of the Board and the Terms of Reference for the Pathway Board reflects these aims and in addition the Board is supported by a Clinical Subgroup which facilitates engagement with secondary care clinicians to ensure there is a focus on strategy and secondary care issues. The 2013-14 Annual Plan set out in detail the ambitions of both Boards, reflecting the overarching objectives of Manchester Cancer.

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1.2. Membership The tables below outline the membership of the Pathway Board and Clinical Subgroup. Table 1. Colorectal Cancer Pathway Board

NAME ROLE TRUST

Paul Harris Colorectal Surgeon Bolton

Mark Saunders Clinical Oncologist

Christie

Vivek Misra Clinical Oncologist

Malcolm Wilson Colorectal Surgeon

Michael Braun Medical Oncologist

Lucy Davidson Radiotherapy Pathways

Alistair Makin Consultant Gastroenterologist CMFT

Rajeev Kushwaha/David Donnelly Colorectal Surgeons

Usman Khan/Mohammed Saddat Colorectal Surgeons East Cheshire

Caroline Bruce Colorectal Surgeon Mid Cheshire

Saad Salman Colorectal Surgeon Pennine

Rahul Deshpande HPB

Amanda Ogden CNS SRFT

Edwin Clark Colorectal surgeon Stockport

Kamran Siddiqui Colorectal Surgeon Tameside

Anna Davenport Consultant Histopathologist

UHSM Samantha Kay/Gill Bulpin Consultant Palliative Care/Macmillan

Specialist Nurse

Debbie West CNS and Palliative Care

Marius Paraoan Colorectal Surgeon WWL

Caroline Whitaker Stoma Care Nurse Other

Sarah Taylor GP

Billie Moores NW Bowel Screening QA Other

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Table 2. Colorectal Cancer Clinical Subgroup

NAME ROLE TRUST

Mr Paul Harris Colorectal Surgeon

David Bisset Consultant Histopathologist Bolton

Rubeena Razaaq Consultant Radiologist

Malcolm Wilson Colorectal Surgeon

Vivek Misra Clinical Oncologist

Michael Braun Consultant Medical Oncologist

Scott Brown Clinical Nurse Specialist The Christie

Mark Saunders Clinical Oncologist

Chelliah Selvasekar Colorectal Surgeon

Rajeev Kushwaha/David Donnelly

Colorectal Surgeons

Deborah Hitchen Clinical Nurse Specialist CMFT

Margaret Parker Clinical Nurse Specialist

Usman Khan/Mohammed Sadat Colorectal Surgeon

Angela Jeff Clinical Nurse Specialist East Cheshire

Simon Ward Colorectal Surgeon

Caroline Bruce Colorectal Surgeon

Heather Hughes Macmillan Colorectal Clinical Nurse Specialist

Mid Cheshire

Dr Ming Tee/Dr De Anirban Consultant Radiologists

Saad Salman Colorectal Surgeon

Peter Byrne Colorectal Surgeon Pennine

Zahirul Huq Colorectal Surgeon

Amanda Ogden Clinical Nurse Specialist

Dominic Slade Colorectal Surgeon Salford

Vicky Kenyon Clinical Nurse Specialist

Edwin Clark Colorectal Surgeon

Sajal Rai Colorectal Surgeon Stockport

Rebecca Costello Clinical Nurse Specialist

Kamran Siddiqui Colorectal Surgeon Tameside

Anna Davenport Consultant Histopathologist

Aswatha Ramesh Colorectal Surgeon UHSM

Dr V Rudralingam Consultant Radiologist

Marius Paraoan Colorectal Surgeon WWL

Yvonne Chantler Clinical Nurse Specialist

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Named leads supporting specific areas of the Pathway listed below: Research – Mike Braun Early Diagnosis & Endoscopy – David Donnelly Living With and Beyond Cancer – Sarah Taylor and Angela Jeff Pathology – Anna Davenport Radiology – Dr V Rudralingam, Dr R Razaaq The Board has yet to secure named leads for education and surgery and will be looking to do this in the near future. The Pathway Board has no patient representative at present and will be working with the newly recruited Macmillan User Involvement Team in achieving this to further develop its understanding of patients’ experience of care. 1.3. Meetings The first meeting of the Board in this financial year took place on 20th May 2014. As colorectal cancer has two separate strata of meetings there is a meeting for each Board three times a year, meetings occurring every 2 months. There is communication between the separate Boards through the dissemination of minutes. The minutes of the meetings are published on Manchester Cancers’ website and can be found here. A full list of meeting dates and a record of attendance can be found in the appendix. In general, both Boards are fairly well attended by all representatives with deputies attending when required. There is an exception in relation to attendance by Trust representatives from WWL and Tameside which has been poor. This will be addressed directly with the trusts involved and this is a component of the 2015-16 plan (objective 4). The Board noted the importance of developing and delivering educational initiatives and held a GP education event on 31st January in conjunction with the Hepato-Pancreatico-Biliary and Upper GI pathways. The event was held at UHSM, and was attended by over 80 GP’s and focused on screening and early diagnosis. The Board will now be exploring the opportunities to deliver a secondary care focused event.

2. Summary of delivery against 2014/15 plan

No Objective Alignment with Provider Board objectives

Tasks By Status Green = achieved Amber = partially achieved Red = not achieved

1 To increase screening uptake to above the national average (by Aug 2019)

Improve 1-year survival

Develop project with PHE and BCSP

Nov 2014 G

Project commencement Nov 2014 G

GP educational event Jan 2015 G

Project evaluation April 2015 A

Further project development with PHE, BCSP

Nov 2014 - onwards

A

2 To improve patients experience of care in line with the National Cancer Survivorship Initiative (by Aug 2019)

Improve patient experience

Introduce survivorship to Pathway Board

July 2014 G

Regional survey of survivorship activity

Sept 2014 G

Presentation of results Nov 2014 G

3 Enhance recruitment of colorectal patients to clinical trials (by Aug 2017)

Increase research and clinical innovation

Regular presentation of clinical trials data/uptake at meetings

ongoing G

Low uptake to be discussed with trusts

ongoing R

Work with CRN to address any imbalances

ongoing R

4 To update network guidelines (by Aug 2016)

High quality care Develop and prioritise list of guidelines requiring update

Aug 2014 G

Identify areas where new guidelines are required

Aug 2014 G

Form working groups to update guidelines

Mar 2015 A

Form working groups to develop new guidelines

Mar 2015 G

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Present and agree guidelines through Pathway Board and Clinical Subgroup

May 2015 A

Assess progress at 1-year June 2015 R

Update and revise work programme as necessary

July 2015 R

5 To monitor, measure and assess colorectal cancer services across the region (by Aug 2016)

High quality care Performance data collated and presented at each meeting

ongoing G

Breach data is analysed and patterns discussed

ongoing G

3. Improving outcomes, with a focus on survival 3.1. Information Incidence and Prevalence Data from the Office for National Statistics (2014) indicates that colorectal cancer continues to be the third most common cancer accounting for 13.4% of all male and 10.9% of all female cancers registered in England in 2012. Table 3. Directly age standardised rates per 100,000 population of newly diagnosed cases of cancer

C00-C97 All cancers M 817.3 820.1 846.5 848.1 870.3 883.8 930.8 928.8 926.7 901.2 884.0

F 591.6 606.4 615.8 626.6 641.1 652.7 687.5 682.0 685.2 673.3 661.7

C18-C20 Malignant neoplasm of M 86.2 87.0 89.0 89.4 89.5 89.8 92.5 92.2 91.5 91.4 90.6

colon and rectum F 54.3 54.1 55.8 56.4 57.1 57.9 58.2 58.5 58.2 58.8 57.6

2011 20122005 2006 2007 2008 2009 20102002 2003 2004ICD-10

CodeSite description

Colorectal cancer is significantly more common in both males and females aged over 60 with a high proportion of new registrations diagnosed in 2012 within the 70 – 80 year range. Table 4. Registration of newly diagnosed cases of cancer sex and age England 2012

C18-C20

Malignant

neoplasm

of M 19,286 486 828 1,309 2,361 2,856 3,092 3,047 2,604 1,530 596

colon and

rectum F 15,036 392 627 933 1,421 1,839 2,091 2,254 2,291 1,635 931

75-79 80-84 85-89 90 and over45-49 50-54 55-59 60-64 65-69 70-74

Mortality Around 6 in 10 (61%) colorectal cancer deaths are due to cancers of the colon, and around 4 in 10 (39%) are due to cancers of the rectum. More rectal cancer deaths occur in men than in women (60% male vs. 40% female), while the proportion of colon cancer deaths is similar between men and women (51% male vs. 49% female). Almost a fifth (18%) of bowel cancer deaths occur in people aged 60-69. Men and women in this age group are currently offered bowel screening in England, and the programme is being extended to include people aged 70-74.

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Figure 1. Colorectal cancer average number of deaths per year and age specific mortality rates UK 2010-2012

Cancer Research UK Data from Cancer Research UK identifies that 77% of men survive colorectal cancer for at least one year, and this is predicted to fall to 59% surviving for five years or more. Survival for women at one and five years is slightly lower, with 74% surviving for one year or more, and 58% predicted to survive for at least five years. As with most cancers, survival for bowel cancer is improving. One-year age-standardised net survival for colorectal cancer in men has increased from 47% during 1971-1972 to 77% during 2010-2011 in England and Wales. In women, one-year survival has increased from 45% to 74% over the same time period.

Routes to diagnosis The National Cancer Intelligence Network (NCIN) use data collated from Hospital Episodes Statistics (HES) data combined with Cancer Waiting Times (CWT) data, data from the cancer screening programme and cancer registration data to categorise all cancers into eight separate routes to diagnosis. Below are the routes to diagnosis for colorectal cancer diagnosed 2006 – 2010 with the routes for all malignant neoplasms as a comparator. This indicates that the two week wait referral, routine GP referral and emergency presentation were the most common routes for diagnosis, with the data for colorectal cancer strongly mirroring the rates for all neoplasms. Screen detected cancers only make up a small percentage of the overall routes to diagnosis but it will be important to bear in mind that the data has been captured prior to the implementation of the National Bowel Cancer Screening Programme. Screening will

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generally detect colorectal cancer at an earlier stage which will improve survival rates. Cancer Research UK indicates one-year relative survival for colorectal cancer is highest for patients presenting at stage one with 98% of men and 100% of women surviving their disease for at least a year as opposed to 40% of men and 33% of women at stage four. Table 5. Percentage of diagnoses by route 2006 - 2010

2006-2010

Scre

en

det

ect

ed

Two

Wee

k

Wai

t

GP

ref

erra

l

Oth

er

Ou

tpat

ien

t

Inp

atie

nt

Elec

tive

Emer

gen

cy

pre

sen

tati

on

Dea

th

Ce

rtif

icat

e

On

ly

Un

kno

wn

Nu

mb

er o

f ca

ses

Colorectal 5% 27% 25% 9% 5% 25% 0% 4% 156,057

All Malignant Neoplasms (excl. NMSC)

5% 27% 27% 10% 3% 23% 0% 4% 1,272,584

3.2. Progress With respect to the target of improving outcomes with a focus on survival, the 2014-15 annual plan set an objective to increase the screening uptake to above the national average. This was identified as an on-going objective to be attained by 2019. The Board have made significant progress in undertaking the tasks identified to facilitate this objective last year. The project to re-engage patients with a positive FOB test back into screening through GP communication was established with the support of PHE and the BCSP and was also able to agree the support of a Project Worker to lead on the project aims and evaluate the findings of the pilot. In addition, the project has been accepted onto the Accelerate, Coordinate and Evaluate (ACE) programme of works which is an NHS England activity looking at a portfolio of 60 projects that will improve the early diagnosis of cancer. Acceptance onto the ACE programme signifies the importance of this project and its potential impact and replication at a national level. Following evaluation, it is anticipated that this will be used to develop further screening initiatives. In conjunction with this activity, last year’s plan indicated that a GP education event focused on screening and early diagnosis would clarify the importance of re-engaging with these patient groups. The event was held in January 2015 and also included education on hepato-pancreatico-biliary and upper GI pathways. 3.3. Challenges Although there has been success in undertaking this objective, it is recognised that it will take more time and further activity to increase local screening uptake to above the national average. It will be important that the findings of the evaluation are captured and work is undertaken with PHE, specifically the screening team, as well as liaison with the Early

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Diagnosis, Screening and Prevention Pathway Board to develop collaborative and targeted initiatives to further tackle population groups of particular concern.

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4. Improving patient experience 4.1. Information Outcomes from the National Patient Experience Survey were initially reviewed in the November Pathway Board meeting. It was recognised that the variance in response rates at individual Trust level made the results difficult to interpret. It was also accepted that standardising information that patients received across the region may help to improve the results to certain questions. This year, patients were asked to highlight key questions from the survey that they felt were particularly significant. These will be monitored by the Manchester Cancer Provider Board as part of their scorecard. In addition, the Board felt that there were questions that would be important to their patient groups, and the performance within these would also be monitored by the Board. Below are the results to a sample of these questions with respect to colorectal cancer by Trust with the national and regional average as a comparator. Trusts with less than 20 responses to a question are not included in the results. Figure 2. NCPES results to questions identified by Manchester Cancer Provider Board

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Figure 3. NCPES results to questions identified by Colorectal Cancer Board

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4.2. Progress With regards to the overall target of improving patient experience, last year’s annual plan set out the objective to improve patient’s experience of care in line with the National Cancer Survivorship Initiative (NCSI). All tasks outlined in the plan have been achieved and substantial additional activity has also taken place. The Colorectal Cancer Board was the first Pathway Board to map current living with and beyond cancer (LWBC) activity at Trust level and the template developed by the Pathway Director was used by the LWBC Pathway Board to map all tumour groups. Although the results of the mapping identified that most Trusts were undertaking survivorship initiatives at some level, it was clear that there was considerable variation in application. To support the further implementation and standardisation of this activity, the Pathway Director applied and was successful in bidding for funding from the LWBC Innovation Fund to develop a CNS group that would work to develop and standardise elements of the recovery package (identified within the NCSI). This will be supported by the recruitment of a Project Worker to work across all Trusts. To date the CNS group have met twice and are in the process of identifying their one- and three-year objectives. Additional steps to progress this area are detailed in the 2015-15 annual plan (objective 2). 4.3. Challenges As stated above, there has been extensive work undertaken to develop this area of work within the Board and this has been supported by the LWBC Innovation Fund. The funding is for one year and will assist the pathway in undertaking LWBC activities that are anticipated to become commissioned responsibilities in the near future. The Board also has two named

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leads for LWBC who will support the Pathway Director in delivering on this agenda and it will be important for all clinicians, trusts and CEOs to support the implementation of the recovery package activities locally.

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5. Increasing research and innovative practice 5.1. Information Last year Greater Manchester Clinical Research Network (GMCRN) recruited 86 patients into interventional and 79 patients into observational colorectal cancer trials. CMFT and the Christie were the two largest recruiting centres recruiting 56 (54 into CORGI) and 48 patients respectively. The pre-operative oral supplementation in colorectal cancer (POSICC) trial recruited patients from the largest number of Trusts. WWL was the trust that recruited the fewest number of patients into trials overall. Trial recruitment is regularly discussed at Board meetings with the Research Lead providing additional data on trials that will open and about to recruit. 5.2. Progress Last year the Colorectal Cancer Pathway Board set the objective to enhance recruitment of colorectal patients to clinical trials. This will be an on-going target for the Board and as such is a standing agenda item on both the Pathway Board and the Clinical Subgroup. Manchester Cancer core team have further developed its relationship with the GMCRN to ensure good access to recruitment data in a timely manner. Several individuals involved with the Colorectal Cancer Pathway Board are active participants in the ongoing Delphi exercise and project run by the Association of Coloproctology of Great Britain and Ireland. This aims to increase development of and recruitment of colorectal patients into colorectal trials across the country. 5.3. Challenges There has been limited discussion relating to the variation in recruitment across Trusts so it is unclear what factors may be impacting on this. It will be important for these discussions to take place and barriers to recruitment at Trust level recorded and progressed as appropriate. This will be an on-going objective of the Board (Objective 3).

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6. Delivering high quality, compliant, coordinated and equitable services

6.1. Information This year the Boards have reviewed a range of data to understand how well colorectal cancer services are performing across the region. The age standardised incidence rate per year recorded in Greater Manchester CCG’s 2010-2012 for colorectal cancers was 78.5 (7085 for all cancers). Within this period there were 680 deaths due to this tumour group which resulted in a mortality rate of 30.2 (313.6 for all cancers). Cancer wait performance The Board has been reviewing the performance of all Trusts with regards to cancer wait times against national targets. Although it is recognised that the number of two week wait referrals have been increasing over the years, most Trusts have been able to maintain the standard of 93% of all patients seen within two weeks. Figure 4. Annual 2WW performance for suspected colorectal cancer by Trust 2014-15

Similarly, the target for 96% of patients to commence treatment within 31 days once being diagnosed is met well by all Trusts across the region. There is a greater challenge for Trusts in meeting the target of ensuring 85% of patients are referred and receive their first treatment within 62 days. This has been recognised as a national and local concern for colorectal services. To support regional understanding of this issue an regional audit led by Pennine cancer services was undertaken this year. It mapped the progress of 15 patients from a range of Trusts and benchmarked their performance against the agreed pathway timetable. It concluded that much of the delays within the pathway occur during the diagnostic stage and recommended straight to test services and less time between MDT discussions and clinic appointments. Manchester Cancer has developed an action plan to

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support the improvement in this cancer wait target across a number of tumour groups and this is the subject of current discussion with the CCGs. Figure 5. Annual 62 day performance by Trust 2014-15

Screening data Regular bowel cancer screening has been shown to reduce the risk of dying from colorectal cancer by 16%. The national programme offers screening to women and men every 2 years between the ages of 60 - 69 and from 2012 the age range was extended to 74. Nationally, the minimum standard for screening uptake is 52% and locally many of the CCG’s in Greater Manchester struggle to achieve this. In particular the cumulative rate for 2014 in North, South and Central Manchester CCGs was significantly below this.

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Table 6. Uptake and positivity rates by Greater Manchester CCGs: January to December 2014 CCG Jan-Mar 14 Apr-Jun 14 Jul-Sept 14 Oct-Dec 14 Jan-Dec 14 (cumulative rate)

Bolton 52.51% 54.97% 58.50% 54.68% 55.27%

Bury 53.14% 61.25% 55.00% 56.19% 56.19%

Central Manchester 35.08% 39.21% 39.29% 37.89% 37.81%

Heywood, Midd & Roch 51.96% 57.90% 53.37% 52.63% 53.91%

North Manchester 39.89% 45.70% 44.13% 41.08% 42.43%

Oldham 50.38% 57.74% 53.66% 51.27% 53.06%

Salford 51.16% 52.13% 55.30% 48.65% 51.82%

South Manchester 42.37% 43.99% 45.39% 41.14% 43.21%

Stockport 53.96% 53.93% 56.37% 53.41% 54.44%

Tameside & Glossop 49.39% 52.08% 52.94% 49.92% 51.07%

Trafford 51.98% 53.53% 56.36% 53.81% 53.91%

Wigan Borough 53.70% 56.12% 60.35% 55.49% 56.47%

North West 54.70% 57.11% 56.60% 54.58% 55.76%

England 58.09% 57.87% 58.46% 56.71% 57.78% There is a national expectation that the number of positive screens (positivity rate) will be below 2%, however those CCG’s that have the lowest uptake have a higher positivity rate than the national average. Figure 6. Positivity rates by Greater Manchester CCG’s – January to December 2014

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Staging at diagnosis The stage at which symptomatic patients are diagnosed is similar across all CCG’s with the majority of patients being diagnosed at stage 2 and 3. This distribution of stage has been the same across colorectal cancers for several years, however this may change in future years following the introduction of the national screening programme, if screening uptake increases significantly. However, at present, screen detected cancers only make up 5% of new diagnoses of colorectal cancer. Table 7. Stage at diagnosis of colorectal cancer by CCG 2012

I % II % III % IV % X %

Bolton 43 22.3 43 22.3 51 26.4 40 20.7 16 8.3

Bury 23 19.7 23 19.7 36 30.8 23 19.7 12 10.3

Central Manchester

12 15.6 17 22.1 21 27.3 22 28.6 5 6.5

Heywood, Middleton, Rochdale

17 15.2 29 25.9 29 25.9 25 22.1 11 9.8

North Manchester

18 21.4 15 17.9 26 31.0 12 14.3 13 13.5

Oldham 25 15.9 31 19.7 46 29.3 34 21.7 20 12.7

Salford 16 10.7 41 27.3 41 27.3 28 18.7 24 16.0

South Manchester

13 11.1 19 16.2 26 22.2 22 18.8 7 6.0

Stockport 32 15.5 42 20.4 62 30.1 52 25.2 18 8.7

Tameside & Glossop

34 17.5 57 39.4 39 20.1 45 23.2 19 9.8

Trafford 25 17.5 24 16.8 42 29.4 30 21.0 22 15.4

Wigan 40 16.1 58 23.4 68 27.4 53 21.4 19 7.7

East Cheshire 26 17.3 53 35.3 32 21.3 26 17.3 13 8.7

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6.2. Progress Last year the Colorectal Board set two objectives in relation to the target of delivering high quality, compliant, co-ordinated and equitable services. The first objective was to update the network guidelines and the second to monitor, measure and assess cancer services across the region. In relation to the first target, there has been significant work undertaken in developing new guidance to meet the requirements of colorectal cancer services and this has been achieved through undertaking audits of current practice and consultation within both Boards and others across the region. These include new guidelines on:

Guidelines for the management of patients receiving short course radiotherapy

Guidelines and pathway for the assessment of mismatch repair status in colorectal cancer

Guidance on testing for K-Ras mutations and updated guidelines on:

Guidelines for laparoscopic colorectal cancer surgery.

Guidelines for the assessment and management of colorectal hepatic metastases There has also been collaboration in the development of guidelines with other pathway boards and the management of colorectal hepatic metastases is an example of this. With regards to the second objective, a range of data has been brought to the Board to review on a regular basis. This includes cancer wait and screening data as well as results from the National Cancer Patient Experience Survey and National Bowel Cancer Audit. Incidences of breaches and outlier performance have been reviewed and communication has taken place at Trust level to better understand the reasons for this performance. An example of this is the work led by Trust Directors of Operations and Cancer Mangers to audit performance in relation to the 62-day cancer wait target. Also, outlying performance in the National Bowel Cancer Audit and National Peer Review has been addressed with the individual trusts concerned and the findings and actions reported to the Manchester Cancer Core Team for feedback to the Provider Board. 6.3. Challenges There has been limited work undertaken to update the guidelines requiring review from the previous Cancer Network. A detailed plan for review of these guidelines will be developed for the forthcoming year but this will require additional clinical support from within the Board. The range of data that can be reviewed by the Board has been significantly impacted by the data that is publically accessible and this was relatively limited in the first year of Manchester Cancer. The Board will continue to review and monitor the data that is currently available and identify when other data items become routinely available.

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7. Objectives for 2015/16 The objectives for 2015-16 will build on the notable work undertaken by the Board last year and in addition reflect on the additional activity that is taking place within the newly established Colorectal Specialist Nurses group. Specifically this will include:

Screening – to evaluate the outcomes of the project implemented last year and build on this work through national and regional engagement and education activities

Living with and beyond cancer – to implement and develop this work stream as identified through the Innovation Fund project and evaluate the progress of the CNS group

Recruitment to trials – to develop a more proactive approach to identifying and supporting low recruiting centres

Clinical guidelines – to develop a robust process to ensure the timely updating of clinical guidelines.

Further detail on the 2015-16 objectives can be found in the Colorectal Cancer Annual Plan.

8. Appendix 1 – Pathway Board meeting attendance

NAME ROLE TRUST 26/02/2014 19/03/2014 (PB) 20/05/2014 (CSG)16/07/2014 (PB)04/09/2014 (CSG)26/11/2014 (PB)20/01/2015 (CSG)

11/03/2015

(PB)

TRUST REPRESENTATIVES

Paul Harris (PB/CSG) Colorectal Surgeon Bolton Apologies Apologies Apologies Apologies deputy

David Bisset (CSG) Consultant

Histopathologist Apologies

Rubeena Razaaq (CSG) Consultant

Radiologist Apologies Apologies Apologies

Malcolm Wilson (PB/CSG) Colorectal Surgeon deputy deputy

Chelliah Selvasekar (CSG) Colorectal Surgeon Apologies Apologies

Scott Brown (CSG)

Clinical Nurse

Specialist Apologies Apologies

Rajeev Kushwaha (PB/CSG) Colorectal Surgeon CMFT

David Donnelly (PB/CSG) Colorectal Surgeon

Deborah Hitchen (CSG) Clinical Nurse

Specialist

Margaret Parker (CSG) Clinical Nurse

Specialist Apologies

Angela Jeff (CSG) Clinical Nurse

SpecialistEast Cheshire

Simon Ward (CSG) Colorectal Surgeon

Usman Khan/Mohammed

Saddat (PB/CSG) Colorectal Surgeon

Caroline Bruce (PB/CSG) Colorectal Surgeon Mid Cheshire Apologies Apologies Apologies deputy deputy

Heather Hughes (CSG) Macmillan

Colorectal Clinical

Nurse Specialist Apologies Apologies

Ming Tee/De Anirban (CSG) Consultant

Radiologist

Saad Salman (PB/CSG) Colorectal Surgeon Pennine

Peter Byrne (CSG) Colorectal Surgeon

Zahirul Huq (CSG) Colorectal Surgeon

Amanda Ogden (PB/CSG) CNS SRFT Apologies Apologies Apologies

Dominic Slade (CSG) Colorectal Surgeon Apologies Apologies Apologies Apologies

Vicky Kenyon (CSG) Clinical Nurse

Specialist

Mr Edwin Clark (PB/CSG) Consultant

colorectal surgeonStockport

Apologies Apologies Apologies

Sajal Rai (CSG) Colorectal Surgeon Apologies Apologies

Rebecca Costello (CSG) Clinical Nurse

Specialist

Kamran Siddiqui (PB/CSG) Colorectal Surgeon Tameside

Anna Davenport (PB/CSG)

Consultant

Histopathologist Apologies Apologies Apologies

Aswatha Ramesh (CSG)

Colorectal Surgeon

Apologies

Dr Rudralingam (CSG)

Consultant

Radiologist

Marius Paraoan (PB/CSG) Colorectal Surgeon WWL Apologies

Yvonne Chantler (CSG)

Clinical Nurse

Specialist

PATHWAY BOARD MEMBERS

Caroline Whitaker (PB) Stoma Care Nurse

Sarah Taylor (PB) GP

Billie Moores (PB) NW Screening QA Apologies

Mark Saunders (PB/CSG) Clinical Oncologist Apologies Apologies

Vivek Misra (PB/CSG) Clinical Oncologist Apologies Apologies

Michael Braun (PB/CSG) Medical Oncologist Apologies Apologies

Lucy Davidson (PB)

Radiotherapy

Pathways Apologies Apologies Apologies

Alistair Makin (PB)

Consultant

Gastroenterologist

Rahul Deshpande (PB) HPB Apologies

Samantha Kay/Gill Bulpin

(PB) Palliative Care Apologies

Debbie West (PB) CNS and Palliative

Christie

COLORECTAL

ATTENDANCE - PATHWAY BOARD MEETING

UHSM

- 27 -

9. Appendix 2 – Pathway Board Annual Plan 2015/16

Colorectal Pathway Board Annual Plan 2015-16

Pathway Clinical Director:

Sarah Duff

Pathway Board Members:

Pathway Manager:

Melissa Wright

Date agreed by Pathway Board:

14th May 2015

Review date:

June 2016

Summary of objectives .

No Objective Alignment with Provider Board objectives

1 To increase screening uptake to above the national average

Improving outcomes, with a focus on survival

2 To enhance living with and beyond cancer services for colorectal cancer patients

Improving patient experience Delivering high quality, compliant, coordinated and equitable services

3 To enhance recruitment of colorectal patients to clinical trials

Increase research and innovative practice

4 To update network guidelines and monitor, measure and assess colorectal cancer services across the region

Delivering high quality, compliant, coordinated and equitable services

Objective 1: To increase screening uptake to above the national average

Objective:

To increase screening uptake to above the national average. This years phased objectives are to: To continue current work with PHE/BCSP to evaluate local GP re-engagement project and determine whether and how this could be continued longer-term. To work with PHE/BCSP and the ACE programme to implement successful measures demonstrated nationally to increase screening uptake locally. To plan a further GP education event with a focus on bowel cancer screening/flexiscope for 2016.

Rationale:

Screen detected colorectal cancers have an earlier stage distribution than symptomatic cancers. Currently only 5% of colorectal cancers are detected through screening. Significantly increasing the uptake of screening will increase the number of cancers diagnosed by this route and increase survival by diagnosing cancers at a curable stage.

By (date):

August 2019 This objective was commenced in the 1st annual plan (2014-2015) and achieving this is a mid-term objective of the Colorectal Pathway Board. The steps outlined in last years plan have all been achieved and will be progressed further as detailed in the coming year.

Board measure(s):

Rates of screening uptake by CCG. Rates of screen diagnosed cancers (via BCSP data and NBOCA). The minimum uptake for screening nationally is set at 52% and Manchester should exceed this target and aim to exceed the national average by 2019.

Risks to success:

Limited ability to influence patient pathway processes surrounding BCSP and within PHE. Extending GP involvement models with the screening hub may require financial assistance which is not immediately available. Screening hub may not perceive value in continuing local projects and may seek a more national focus. Engaging in the ACE programme may mean that Manchester Cancer can be involved in these developments as they evolve.

Support required:

To encourage CCGs to increase GP awareness of the importance of bowel cancer screening and its ability to make early diagnosis a reality.

The programme of work through which the Pathway Board will achieve the objective should be outlined below. This can take whatever form the Pathway Board considers appropriate. Two suggested formats are provided.

Work programme

Action Resp. By (date)

GP re-engagement project evaluation Shenna Paynter (SP)

June 2015

GP re-engagement project presentation SP PB meeting July 2015

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Determine outcome and sustainability of GP re-engagement project SP, SD, BM

Sept 2015

National ACE cluster meeting SP, SD 16th Sept 2015

Liaise with PHE and BCSP to determine future work streams – ACE models, GP re-engagement project

SP, SD, BM

Dec 2015

Start to plan GP educational event for 2016 SD, education lead (TBC)

April 2016

Work programme

Task Resp.

June-July

Aug- Sept

Oct - Nov

Dec-Jan

Feb-March

Apr - May

June-July

Aug-Sep

GP re-engagement project evaluation

SP

GP re-engagement project presentation

SP

Determine outcome and sustainability of GP re-engagement project

SP,SD,BM

National ACE cluster meeting

SP,SD

Liaise with PHE and BCSP to determine future work streams – ACE models, GP re-engagement project

SP, SD, BM

Start to plan GP educational event for 2016

SD and Education lead

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Objective 2: To enhance living with and beyond cancer services for colorectal cancer patients

Objective:

All colorectal cancer patients should benefit from access to all elements of the Recovery Package during and following their treatment. This years phased objectives are to: Establish a CNS group to determine 1 and 3 year objectives for progress towards implementing the Recovery Package in all trusts Appoint a Macmillan Colorectal LWBC project manager to help trusts define and work towards their objectives To hold a Recovery Package Education meeting for the CNS group To hold regular CNS meetings to discuss progress and problems To develop a pathway for late effects assessment and treatment That all trusts should have a plan for the introduction of end of treatment information summaries for patients and GPs

Rationale:

A survey performed by the Colorectal Pathway Board in 2014 showed that although most trusts implement some elements of the recovery package, this is variable across the region and inconsistent. The aim is to achieve consistency and high quality care with excellent experience for patients. Implementation of stratified pathways for follow-up care will also enhance patients confidence in self-management and healthy living which will impact on the health of the wider population.

By (date):

The objective to ‘improve patients experience of care in line with the National Cancer Survivorship Initiative’ was introduced as an objective in the 2014/15 annual plan. All the components of last years plan were achieved. This current objective is a continuation of this same topic. The target date for completion is August 2019 and this years steps towards this goal are detailed above.

Board measure(s):

The LWBC PB plan to perform a pan-site audit in 2015/16 for experience of life after cancer, the findings of this audit will inform progress. A baseline of Recovery Package implementation is set from the 2014 regional audit, a further audit will be performed at the end of the LWBC project managers post to track progress to date.

Risks to success:

Limited influence to facilitate change in individual trusts and relying on individuals within the CNS group to develop and make change within their trusts, these individuals are already busy with their own roles and may find this hard to achieve. The Macmillan Colorectal LWBC project manager may be able to inspire and help the CNS to make the necessary progress and service specification change from the CCGs may promote the Recovery Package as a requirement from trusts.

Support required:

To present at CEO level the importance of the Recovery Package to patient experience and outcomes and encourage engagement with the LWBC agenda using the resources from the Macmillan Innovation Fund/Project Manager to enhance activities that their trust is already doing. To ask CEOs to make end of treatment summary information a requirement for their cancer pathways.

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The programme of work through which the Pathway Board will achieve the objective should be outlined below. This can take whatever form the Pathway Board considers appropriate. Two suggested formats are provided.

Work programme

Action Resp. By (date)

Establish CNS group and set objectives SD May 2015

Recovery Package Educational meeting SD/Macmillan 16th June 2015

Appoint Macmillan Colorectal LWBC project manager (through Macmillan Innovation Fund)

SD, AJ, Karen Blackburn

July 2015

Regular meetings of CNS group SD, MW, Project Manager

July, Sept, Nov 15 dates confirmed

Evaluate progress of CNS group Project Manager

April –June 2016

Develop pathway for late effects Project Manager, SD, AJ

June 2016

Determine progress towards end of treatment summaries Project Manager

June 2016

Work programme

Task Resp.

June-July

Aug- Sept

Oct - Nov

Dec-Jan

Feb-March

Apr - May

June-July

Aug-Sep

Establish CNS group and set objectives

SD

Recovery Package Educational meeting

SD/Macmillan

Appoint Macmillan Colorectal LWBC project manager (through Macmillan Innovation Fund)

SD.AJ, Karen Blackburn

Regular meetings of CNS group

SD, MW Project Manager

Evaluate progress of CNS group

Project Manager

Develop pathway for late effects

Project Manager, SD, AJ

Determine progress towards end of treatment summaries

Project Manager

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Objective 3: To enhance recruitment of colorectal patients to clinical trials

Objective:

To enhance recruitment of colorectal patients to clinical trials and ensure trial availability and information is available to all sites. To address variability in research participation between sites and identify barriers and reasons for this and progress them.

Rationale:

Manchester Cancers objective is to increase the proportion of patients involved in trials to 40% by 2019. In order to do so, regular trial participation and knowledge about available trials is essential for participating clinicians.

By (date):

This objective was introduced in the 2014-15 annual plan with a target date for completion of 2017.

Board measure(s):

Research update is a standing agenda item on each PB meeting and current trials are discussed at each meeting. Trust participation figures are also discussed when available from the CRN. All trusts should demonstrate participate in key trials.

Risks to success:

Little ability to make busy clinicians engage as Principal Investigators for national trials without previous positive experience of research at a site. Low recruiting sites may not have the necessary infrastructure to deliver these objectives. These barriers need to be identified and discussed at PB level.

Support required:

The programme of work through which the Pathway Board will achieve the objective should be outlined below. This can take whatever form the Pathway Board considers appropriate. Two suggested formats are provided.

Work programme

Action Resp. By (date)

Research update and discussion as a regular agenda item for all meetings

MB ongoing

Review 2014 CRN reports to determine participation in key trials MB/SD/MW Sept 2015

Discuss participation rates at CSG meeting, determine areas of difficulty

MB/SD Jan 2016

Approach low recruiting sites to progress further MB/SD April 2016

Work programme

Task Resp.

June-July

Aug- Sept

Oct - Nov

Dec-Jan

Feb-March

Apr - May

June-July

Aug-Sep

Research update and discussion as a regular agenda item for all meetings

MB

33

Review 2014 CRN reports to determine participation in key trials

MB/SD/MW

Discuss participation rates at CSG meeting, determine areas of difficulty

MB

Approach low recruiting sites to progress further

MB/SD

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Objective 4: To update network guidelines and monitor, measure and assess colorectal cancer services across the region

Objective:

To update the guidelines produced by the GMCCN and to continually monitor, measure and assess the colorectal cancer services provided across the region.

Rationale:

To ensure equality of access to services and high quality care across the region against nationally articulated standards.

By (date):

The update of network guidelines was a target for the annual plan 2014-15 with a completion date of 2016. Monitoring, measuring and assessing colorectal services is a continual and ongoing target and addressed contemporaneously at each meeting throughout the year.

Board measure(s):

Use of annual NBOCA data, in particular adjusted 2-year mortality and 90-day mortality. Trust performance against nationally recognised Cancer Wait Times data.

Risks to success:

Limited time available to dedicate to guideline uptake and engage busy clinicians to participate with this objective. Some trusts participation in the activity of the Pathway Board has been suboptimal and this hinders full discussion of problems faced by these trusts. A more proactive approach to guideline update will be taken and the PB members of trusts with less involvement will be approached directly to try to increase engagement.

Support required:

Manchester Cancer needs to inform relevant CEOs of their trusts lack of engagement in the Colorectal Pathway Board.

The programme of work through which the Pathway Board will achieve the objective should be outlined below. This can take whatever form the Pathway Board considers appropriate. Two suggested formats are provided.

Work programme

Action Resp. By (date)

Data presentation SD/MW Ongoing agenda item

Trust non-engagement addressed SD Aug 2015

List of updated guidelines and guidelines for update to be formulated

SD/MW Aug 2015

List circulated and all members requested to sign-up to update a guideline

MW Sept 2015

Groups for guideline update circulated MW Oct 2015

Guideline updates complete PB/CSG members

Dec 2015

Updated guidelines presented PB/CSG members

CSG mtg Jan 2016 (date TBC)

Feedback on guidelines PB/CSG members

Feb 2016

Guideline review SD/PB/CSG PB mtg March

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members 2016 (date TBC)

All guidelines completed and formalised PB/CSG members

CSGmeeting May 2016 (date TBC)

Work programme

Task Resp.

June-July

Aug- Sept

Oct - Nov

Dec-Jan

Feb-March

Apr - May

June-July

Aug-Sep

Data presentation SD/MW

Trust non-engagement addressed

SD

List of updated guidelines and guidelines for update to be formulated

SD/MW

List circulated and all members requested to sign-up to update a guideline

MW

Groups for guideline update circulated

MW

Guideline updates complete

PB/CSG

Updated guidelines presented

PB/CSG

Feedback on guidelines

PB/CSG

Guideline review SD/PB/CSG

All guidelines completed and formalised

PB/CSG

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Appendix: Manchester Cancer Provider Board objectives

1. Improving outcomes, with a focus on survival

We aim to:

have a cancer survival rate for all cancers one year after diagnosis that is consistently higher than the England average for patients diagnosed beyond 2012

have a one-year survival rate higher than 75% for patients diagnosed in 2018

narrow the gap with Sweden’s one-year survival rate from 12% (now) to 6% for patients diagnosed in 2020

approach Sweden’s one-year survival rate by 2025, and

have greater than 70% of cancer patients diagnosed in 2020 survive at least five years

2. Improving patient experience

We aim to:

improve year-on-year the patient experience across the region (as measured by the National Cancer Patient Experience Survey), and

have the best performance in core patient experience questions of any major city area in England by 2015

3. Increasing research and innovative practice

We aim to:

increase the proportion of patients involved in clinical trials from 30% to more than 40% by 2019

4. Delivering high quality, compliant, coordinated and equitable services

We aim to:

support our specialist commissioning colleagues to deliver compliance in the four historically non-compliant specialist cancer surgery services (oesophago-gastric, hepato-pancreato-biliary, gynaecology and urology) by December 2015, and

maintain regional compliance with the national cancer 62-day waiting time target

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10. Appendix 3 Colorectal Clinical Research Trials Annual Report 2014-15

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